Family Medicine Center of the Bitterroot, P.C.

Transcription

1 PATIENT REGISTRATION / FINANCIAL AGREEMENT Thank you for taking time to complete this form. This information is necessary for the preparation of your clinic records. You are responsible for all charges as billed. PLEASE INFORM RECEPTIONIST IF VISIT IS WORKER S COMP OR AUTO ACCIDENT RELATED. PLEASE PRINT AND COMPLETE THE ENTIRE FORM. WE ARE UNABLE TO BILL INSURANCE WITHOUT BIRTH DATES AND SS#. PATIENT INFORMATION Patient Name: First Middle Last Gender M / F Birthdate SS# Mailing address Phone: home: cell: EMPLOYER INFORMATION Employer Name Employer address Employer Phone: Occupation: Which pharmacy do you typically use? EMERGENCY CONTACT INFORMATION Name: Phone: Alt. Phone: Address: IF PATIENT IS A MINOR Mother s Name: Mailing address Birthdate SS# Mother s Employer: Employer s Phone Number: Father s Name: Mailing address Birthdate SS# Father s Employer: Employer s Phone Number: IF PATIENT IS AN ADULT Married Single Divorced Widowed If married: Spouse s Name Phone Birthdate SS# Spouse s Employer: Employer s Phone Number: INSURANCE If you have NO insurance, check here: Name of Insurance Company _ Policy Holder s Name: First Middle Last Policy Holder s ID # Group Number _ Name of Secondary Insurance Company Policy Holder s Name: Policy Holder s ID # Group Number _ *** Please provide copies of your insurance cards to the receptionist to insure accurate billing. I authorize the release of any medical information which may be requested to process claims for payment of medical services through my insurance carrier, prepaid medical plan, or government agency. I authorize payments to be made to the clinic or it s physicians. I assume liability for all non-covered charges and deductibles. By providing a mobile/ cell number I have authorized contact through that number for any activity involving services to me, including but not limited to the resolution of balances on my account. This number will not be shared with any party other than those in-house or any business entity contracted to perform duties resulting from services provided to me by this office. By signing this form I acknowledge that I have received a copy of the Notice of Privacy Practices of Family Medicine Center of the Bitterroot. Signature of Responsible Person Date Relationship FMC-1101

2 Payment Policy Thank you for choosing us as your primary care provider. We are committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request. 1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. 2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit. 3. Non-covered services. Please be aware that some and perhaps all o f the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit. 4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. 5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract. 6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you. 7. Payment. If your payment is made in full at the time of service, a discount will be applied to the balance. 8. Nonpayment. If your account is over 60 days past due, you will receive notification stating that you have two weeks to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our physician will only be able to treat you on an emergency basis. Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines: Signature of patient or responsible party Date FMC 1106

3 Prescription Refills Dear Patient, We take our commitment to your health seriously and prescribing medicine is an important service we provide to you. For this reason, we ask that you follow these guidelines when refilling your prescription medicines. 1. Office visits are almost always required to obtain a prescription drug refill. The reason for this is to evaluate the particular disease or condition that the drug is treating and also to monitor for any drug side effects. 2. We intentionally will give you enough refills of your medicine until we need to see you again. 3. Each prescription will indicate the length of time it is good for and how many times the prescription can be refilled by the pharmacy. If you take several medicines, we try to synchronize the prescriptions so that they can all be refilled at the same visit in order to use your time more efficiently and your money more effectively. 4. When you have one month remaining of your last refill, you need to call and make an appointment to see your doctor. Sometimes, blood tests are needed before you see your doctor and these should be scheduled as well. 5. We generally do not call pharmacy numbers for refills. 6. We feel that telephone refills are not the best way of refilling medicine and will only do so as a short term service. We ask that you only request telephone refills in an emergency. 7. Please discuss any concerns with your physician.

4 330 North 10th Street, Suite A Hamilton, MT Phone: 363-DOCS(3627) Fax: ADULT PATIENT HISTORY Date: Name: Race/Ethnicities (You may decline to answer, however, please note that different races are associated with different health risk factors) Occupation: Marital Status: S M W D Religion: (Optional) Ages of Children: FOR WOMEN: No. of pregnancies: No. of deliveries: No. of miscarriages: Type of contraception: Last Pap smear: Last Mammogram: Last Dexa scan: History of abnormal Pap smear: Yes No ALLERGIES (meds, foods, pollens) IMMUNIZATION (Date of last.) Pneumonia: Tetanus: Influenza: Do you have any acute or chronic pain? If so, what pain medications are you taking? CURRENT MEDICATIONS (Please list all, both prescription and over the counter medications) MEDICAL PROBLEMS (If none, so state) YEAR (Include all hospitalizations, past and present illnesses) SURGERIES/PROCEDURES (If none, so state) YEAR FAMILY HISTORY Age now Age at death Illnesses Father Mother Sister(s) Brother(s) Children FAMILY HISTORY - Please write in relatives who have had the following: Allergies Arthritis Asthma Cancer (type) Diabetes Epilepsy Glaucoma Heart disease High blood pressure HABITS: High cholesterol or lipids Mental/emotional problems Migraine Stroke Suicide Other inherited diseases Do you smoke cigarettes? Yes No If yes, how much? How long? Have you ever smoked cigarettes? Yes No When did you last quit? Do you use other forms of tobacco? Yes No What kind? How much? How many cups of coffee, tea, or cola do you drink per day? Total number of beers, glasses of wine, or mixed drinks per week? What type of exercise do you get regularly? How often? How often do you use seat belts? 25% 50% 75% 100% Please Fill Out Reverse Side

5 MEDICAL PROBLEMS: Give the year you had the problem or a if you have it now. ear trouble eye trouble frequent colds frequent headaches hayfever sinus trouble asthma lung trouble tuberculosis blood cholesterol or lipid elevation heart murmur heart trouble high blood pressure phlebitis rheumatic fever varicose veins vein problem bowel trouble diverticulosis/diverticulitis gallbladder trouble hemorrhoids jaundice/hepatitis liver trouble pancreas problem stomach or duodenal ulcer breast lumps DES exposure hernia kidney or urinary troubles menstrual problems prostate trouble sexually transmitted diseases arthritis gout back trouble neck trouble bone fracture or joint injury anemia blood disorder diabetes thyroid problems seizures/epilepsy neurologic disorder stroke or paralysis alcoholism drug abuse emotional problem sexual problems suicide attempt cancer congenital condition skin disease weight problem asbestos exposure radiation therapy Any other problems: SYMPTOMS: if you have any of the following: ear pain decreased hearing persistent hoarseness blood in sputum frequent cough shortness of breath on exertion lying flat chest pains fainting or dizziness leg pain when walking swollen ankles unusual or irregular heartbeat abdominal pains bloody or tarry stools change in appetite constipation diarrhea difficulty swallowing indigestion persistent nausea or vomiting blood in urine difficulty controlling urine pain while urinating urinating at night (more than 2 times) discharge from penis difficulty having erection urethral discharge vaginal discharge breast lumps nipple discharge hot flashes pain with intercourse leg cramps muscle weakness painful joints bruise easily memory loss numbness/tingling tremor weakness change in sleep pattern feelings of despair usually nervous fever night sweats usually tired Your reason for requesting an appointment? NAME